Surgical evacuation with intraoperative ultrasound (SEE U): A randomised controlled trial

OBJECTIVES

To test whether intraoperative ultrasound can reduce the incidence of early and late complications following surgical removal of products of conception.

DESIGN

This was a prospective, multicentre, randomised, open clinical trial to assess feasibility. It was performed in two University Teaching hospitals in the West Midlands, England. The population consisted of women aged 16 years or over who were referred for surgical management of miscarriage. Patients were randomised to surgical management of miscarriage with either continuous intraoperative ultrasound or without intraoperative ultrasound. Process outcomes included the proportion of eligible women screened and proportion of eligible women randomised, attrition rates, evaluation of outcome measurement tools and acceptability. The primary clinical outcome was a composite outcome of unsuccessful procedure or a complication.

RESULTS

Fifty-nine women requiring surgical management of miscarriage were randomised. The conversion rate for entry into the trial was 59/79(75 %; 95 %CI = 64-84 %). The composite clinical outcome was attained in 5/27(19 %) patients who had surgery without ultrasound and 7/28(25 %) patients who had surgery with ultrasound (RR = 0.74;95 %CI = 0.26, 2.10). When we excluded the patients that could not attend their hysteroscopy appointment, due to COVID-19 pandemic, 5/27(19 %) of patients who had surgery without ultrasound and 5/25(20 %) of patients who had surgery with ultrasound attained the composite clinical outcome (RR = 0.93;95 %CI = 0.30, 2.90).

CONCLUSIONS

This multicentre pilot study showed that a large RCT comparing surgical management of miscarriage with and without intraoperative ultrasound is feasible.

Ulipristal acetate versus levonorgestrel-releasing intrauterine system for heavy menstrual bleeding (UCON): a randomised controlled phase III trial

Background

Heavy menstrual bleeding affects one in four women and negatively impacts quality of life. Ulipristal acetate is prescribed to treat symptoms associated with uterine fibroids. We compared the effectiveness of ulipristal acetate and the levonorgestrel-releasing intrauterine system at reducing the burden of heavy menstrual bleeding, irrespective of the presence of fibroids.

Methods

This randomised, open-label, parallel group phase III trial enrolled women over 18 years with heavy menstrual bleeding from 10 UK hospitals. Participants were centrally randomised, in a 1:1 ratio, to either three, 12-week treatment cycles of 5 mg ulipristal acetate daily, separated by 4-week treatment-free intervals, or a levonorgestrel-releasing intrauterine system. The primary outcome, analysed by intention-to-treat, was quality of life measured by the Menorrhagia Multi-Attribute Scale at 12 months. Secondary outcomes included menstrual bleeding and liver function. The trial is registered with ISRCTN, 20426843.

Findings

Between June 5th, 2015 and February 26th, 2020, 236 women were randomised, either side of a recruitment suspension due to concerns of ulipristal acetate hepatoxicity. Subsequent withdrawal of ulipristal acetate led to early cessation of recruitment but the trial continued in follow-up. The primary outcome substantially improved in both groups, and was 89, (interquartile range [IQR] 65 to 100, n = 53) and 94, (IQR 70 to 100, n = 50; adjusted odds ratio 0.55, 95% confidence interval [CI] 0.26-1.17; p = 0.12) in the ulipristal and levonorgestrel-releasing intrauterine system groups. Rates of amenorrhoea at 12 months were higher in those allocated ulipristal acetate compared to levonorgestrel-releasing intrauterine system (64% versus 25%, adjusted odds ratio 7.12, 95% CI 2.29-22.2). Other outcomes were similar between the two groups and there were no cases of endometrial malignancy or hepatotoxicity due to ulipristal acetate use.

Interpretation

Our findings suggested that both treatments improved quality of life. Ulipristal was more effective at inducing amenorrhoea. Ulipristal has been demonstrated to be an effective medical therapeutic option but currently its use has restrictions and requires liver function monitoring.

Funding

UK Medical Research Council and National Institute of Health Research EME Programme (12/206/52).

Extinct in the wild: The precarious state of Earth's most threatened group of species

Extinct in the Wild (EW) species are placed at the highest risk of extinction under the International Union for Conservation of Nature Red List, but the extent and variation in this risk have never been evaluated. Harnessing global databases of ex situ animal and plant holdings, we report on the perilous state of EW species. Most EW animal species-already compromised by their small number of founders-are maintained at population sizes far below the thresholds necessary to ensure demographic security. Most EW plant species depend on live propagation by a small number of botanic gardens, with a minority secured at seed bank institutions. Both extinctions and recoveries are possible fates for EW species. We urgently call for international effort to enable the latter.

Adapting Agriculture to Climate Change: A Synopsis of Coordinated National Crop Wild Relative Seed Collecting Programs across Five Continents

The Adapting Agriculture to Climate Change Project set out to improve the diversity, quantity, and accessibility of germplasm collections of crop wild relatives (CWR). Between 2013 and 2018, partners in 25 countries, heirs to the globetrotting legacy of Nikolai Vavilov, undertook seed collecting expeditions targeting CWR of 28 crops of global significance for agriculture. Here, we describe the implementation of the 25 national collecting programs and present the key results. A total of 4587 unique seed samples from at least 355 CWR taxa were collected, conserved ex situ, safety duplicated in national and international genebanks, and made available through the Multilateral System (MLS) of the International Treaty on Plant Genetic Resources for Food and Agriculture (Plant Treaty). Collections of CWR were made for all 28 targeted crops. Potato and eggplant were the most collected genepools, although the greatest number of primary genepool collections were made for rice. Overall, alfalfa, Bambara groundnut, grass pea and wheat were the genepools for which targets were best achieved. Several of the newly collected samples have already been used in pre-breeding programs to adapt crops to future challenges.

Conscious sedation for office hysteroscopy: A systematic review and meta-analysis

OBJECTIVE

To evaluate the role of conscious sedation on pain control in office hysteroscopy.

METHODS

MEDLINE, EMBASE, CINAHL and CENTRAL were searched from inception to the 30th October 2020 in order to perform a systematic review and meta-analysis of all randomized controlled trials investigating women undergoing office hysteroscopic procedures, allocated to either conscious sedation or a suitable comparator, where the outcome was pain. Data regarding adverse events, feasibility and satisfaction/acceptability were also collected. The Risk of Bias 2 tool was used to assess study quality. Standard mean differences (SMD) or Odds Ratios (OR), and their 95% confidence intervals (CIs) were calculated for continuous (e.g. mean pain) and dichotomous (e.g. side-effects) outcomes, respectively.

RESULTS

The literature search returned 339 results, of which seven studies were included for systematic review, with five studies having data suitable for meta-analysis. Intravenous conscious sedation, when compared with local anesthesia, reduced pain during (SMD -0.26, 95% CI -0.51 to -0.01), but not after (SMD -0.18, 95% CI -0.43 to 0.07) office hysteroscopy. No significant difference in side-effects were noted (OR 15.58, 95% CI 0.08 to 2891.91). Intravenous conscious sedation, when compared to an oral analgesic and antispasmodic, was associated with increased pain, both during (SMD 1.03, 95% CI 0.56 to 1.49) and after (SMD 0.49, 95% CI 0.04 to 0.93) hysteroscopy and had significantly more side-effects (OR 134.33, 95% CI 16.14 to 1118.17). Inhalational conscious sedation (70% N₂O/30% O₂), when compared to oral analgesia and anxiolysis, showed the greatest reduction in pain during hysteroscopy (SMD -1.04, 95% CI -1.57 to -0.52), however side-effects were not reported. Whilst patients and hysteroscopists were more satisfied with deeper levels of sedation, resulting side-effects, such as delirium, increased the level of post-procedural attention required, leading to a significantly lower level of satisfaction amongst nursing staff.

CONCLUSION

The routine use of conscious sedation in contemporary hysteroscopic practice should be avoided in the absence of any clear reduction in pain and a higher risk of side-effects.

Pain and Operative Technologies used in Office Hysteroscopy: A Systematic Review of Randomized Controlled Trials

OBJECTIVE

To identify technologies associated with the least operative pain in women undergoing operative office hysteroscopic procedures.

DATA SOURCES

MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials were searched until January 2021 using a combination of keywords "hysteroscop*," "endometrial ablation," "outpatient," "ambulatory," "office," and associated Medical Subject Headings.

METHODS OF STUDY SELECTION

Randomized controlled trials evaluating the effect of hysteroscopic devices on pain experienced by women undergoing operative office hysteroscopy were included. Data were also collected regarding efficacy, procedural time, adverse events, and patient/clinician acceptability and/or satisfaction.

TABULATION, INTEGRATION, AND RESULTS

The search returned 5347 records. Ten studies provided data for review. Two trials compared endometrial ablation using bipolar radiofrequency with thermal balloon energy, with no significant difference in pain observed (p <.05). Seven trials evaluated technologies for endometrial polypectomy, of which, 4 compared energy modalities: miniature bipolar electrode resection against resectoscopy (N = 1), morcellation (N = 2), and diode laser resection (N = 1). Two studies compared hysteroscope diameter, and one study compared methods of polyp retrieval. A significant reduction in pain was found using morcellators rather than miniature bipolar electrosurgical devices (p <.001), 22Fr rather than 26Fr resectoscopes (p <.001), and 3.5-mm fiber-optic hysteroscopes with 7Fr forceps rather than 5-mm lens-based hysteroscopes with 5Fr forceps (p <.05). One study investigating septoplasty showed significant reduction in pain when cold mini-scissors, rather than a miniature bipolar electrode, were used (p = .013). Average procedural times ranged from 5 minutes 28 seconds to 22 minutes. The incidence of adverse events was low, and data regarding efficacy and acceptability/satisfaction were limited.

CONCLUSION

Pain is reduced when mechanical technologies such as morcellators and scissors are used compared with electrical devices for removing structural lesions in the office. For hysteroscopic and ablative procedures, smaller and quicker devices are less painful. Large-scale RCTs investigating patient pain and experience with modern operative devices in the office setting are urgently needed.

Cervical dilatation and preparation prior to outpatient hysteroscopy: a systematic review and meta-analysis

BACKGROUND

There are uncertainties about the benefit of routine cervical preparation and/or cervical dilatation before outpatient hysteroscopy.

OBJECTIVE

To determine if cervical preparation and/or routine mechanical dilatation reduces pain during outpatient hysteroscopy.

SEARCH STRATEGY

MEDLINE, EMBASE, CINAHL and CENTRAL were searched on 19 October 2020, using keywords 'hysteroscopy', 'cervical preparation', 'cervical ripening', 'cervical dilatation', 'outpatient', 'office' and/or 'ambulatory' and associated medical subject headings.

SELECTION CRITERIA

Randomised controlled trials investigating the benefit of cervical preparation and/or cervical dilatation on pain in women undergoing outpatient hysteroscopy were included.

DATA COLLECTION AND ANALYSIS

Two independent reviewers selected eligible trials and extracted data on pain, feasibility, adverse events and satisfaction/acceptability for meta-analysis.

MAIN RESULTS

The literature search yielded 807 records, of which 24 were included for review and 19 provided data for meta-analysis. No trials investigated the role of routine mechanical cervical dilatation. Cervical preparation significantly reduced pain during outpatient hysteroscopy; standard mean difference (SMD) -0.67, 95% confidence interval (CI) -1.05 to -0.29. Feasibility also improved as priming provided significantly easier hysteroscopic entry (SMD 0.89, 95% CI 0.32-1.46), greater cervical dilatation (SMD 0.81, 95% CI 0.08-1.53) and shorter procedural times (SMD -0.51, 95% CI -0.88 to -0.13). Cervical preparation, however, incurred significantly more adverse effects, mainly comprising genital tract bleeding, abdominal pain and gastrointestinal symptoms (odds ratio 2.94, 95% CI 1.58-5.47). There were limited data regarding satisfaction, acceptability and complications.

CONCLUSIONS

Cervical preparation reduces pain and improves feasibility associated with outpatient hysteroscopy but increases the risk of adverse effects.

TWEETABLE ABSTRACT

Cervical preparation before outpatient hysteroscopy reduces pain, enhances feasibility but increases adverse effects.

The Prevalence of Thyroid Dysfunction and Autoimmunity in Women With History of Miscarriage or Subfertility

OBJECTIVE

To describe the prevalence of and factors associated with different thyroid dysfunction phenotypes in women who are asymptomatic preconception.

DESIGN

Observational cohort study.

SETTING

A total of 49 hospitals across the United Kingdom between 2011 and 2016.

PARTICIPANTS

Women aged 16 to 41years with history of miscarriage or subfertility trying for a pregnancy.

METHODS

Prevalences and 95% confidence intervals (CIs) were estimated using the binomial exact method. Multivariate logistic regression analyses were conducted to identify risk factors for thyroid disease.

INTERVENTION

None.

MAIN OUTCOME MEASURE

Rates of thyroid dysfunction.

RESULTS

Thyroid function and thyroid peroxidase antibody (TPOAb) data were available for 19213 and 19237 women, respectively. The prevalence of abnormal thyroid function was 4.8% (95% CI, 4.5-5.1); euthyroidism was defined as levels of thyroid-stimulating hormone (TSH) of 0.44 to 4.50 mIU/L and free thyroxine (fT4) of 10 to 21 pmol/L. Overt hypothyroidism (TSH > 4.50 mIU/L, fT4 < 10 pmol/L) was present in 0.2% of women (95% CI, 0.1-0.3) and overt hyperthyroidism (TSH < 0.44 mIU/L, fT4 > 21 pmol/L) was present in 0.3% (95% CI, 0.2-0.3). The prevalence of subclinical hypothyroidism (SCH) using an upper TSH concentration of 4.50 mIU/L was 2.4% (95% CI, 2.1-2.6). Lowering the upper TSH to 2.50 mIU/L resulted in higher rates of SCH, 19.9% (95% CI, 19.3-20.5). Multiple regression analyses showed increased odds of SCH (TSH > 4.50 mIU/L) with body mass index (BMI) ≥ 35.0 kg/m2 (adjusted odds ratio [aOR] 1.71; 95% CI, 1.13-2.57; P = 0.01) and Asian ethnicity (aOR 1.76; 95% CI, 1.31-2.37; P < 0.001), and increased odds of SCH (TSH ≥ 2.50 mIU/L) with subfertility (aOR 1.16; 95% CI, 1.04-1.29; P = 0.008). TPOAb positivity was prevalent in 9.5% of women (95% CI, 9.1-9.9).

CONCLUSIONS

The prevalence of undiagnosed overt thyroid disease is low. SCH and TPOAb are common, particularly in women with higher BMI or of Asian ethnicity. A TSH cutoff of 2.50 mIU/L to define SCH results in a significant proportion of women potentially requiring levothyroxine treatment.

Vaginoscopy for office hysteroscopy: A systematic review & meta-analysis

OBJECTIVE

To investigate the effect of the vaginoscopic approach to office hysteroscopy on patients' experience of pain, when compared with the traditional approach where a vaginal speculum is used.

METHODS

Medline, Embase, CINAHL and the Cochrane library were searched from inception until December 2019, in order to perform a systematic review and meta-analysis of all randomised controlled trials investigating vaginoscopy compared to traditional hysteroscopy on pain experienced by women undergoing diagnostic or operative hysteroscopy in an office setting. Data regarding procedural time, feasibility, incidence of vasovagal reactions and complications, acceptability and satisfaction were also recorded.

RESULTS

The literature search returned 363 results of which seven were selected for systematic review, and six for meta-analysis. The vaginoscopic approach was associated with a statistically significant reduction in pain (4 studies including 2214 patients; SMD -0.27, 95 % CI -0.48 to -0.06), procedural time (6 studies including 2443 patients; SMD -0.25, 95 % CI -0.43 to -0.08) and the incidence of vasovagal episodes (3 studies including 2127 patients; OR 0.35; 95 % CI 0.15 to 0.82). Failure rates between the two techniques were similar (p = .90). No study reported significant differences in complications or patient or clinician acceptability or satisfaction.

CONCLUSION

Clinicians performing office hysteroscopy should use the vaginoscopic technique because it makes office hysteroscopy quicker, less painful and reduces the likelihood of inducing a vasovagal reaction. The traditional approach should only be used when vaginoscopy fails or when the need for cervical dilatation is anticipated.

Local anaesthesia for office hysteroscopy: A systematic review & meta-analysis

OBJECTIVE

To compare the effects of different types and routes of administration of local anaesthetic for pain control during and after office hysteroscopy.

METHODS

Medline, Embase, CINAHL and the Cochrane library were searched from inception until October 2019, in order to perform a systematic review and meta-analysis of all randomised controlled trials investigating the use of a local anaesthetic compared to a control, for pain relief in women undergoing diagnostic or operative office hysteroscopy. Average pain scores and data regarding side-effects, feasibility, complications, acceptability and satisfaction were collected.

RESULTS

The literature search yielded 612 citations. A total of 37 studies were included for systematic review, of which data from 20 studies were used for meta-analysis. Local anaesthesia was associated with significantly reduced pain during (SMD -0.57, 95 % CI -0.79 to -0.34) and after (SMD -0.30, 95 % CI -0.54 to -0.06) office hysteroscopy but did not reduce vasovagal episodes (OR 0.73, 95 % CI 0.50-1.09). A reduction in intra-procedural pain was observed regardless of type or route of administration. Local anaesthesia did not significantly reduce the risk of procedural failure (OR 0.72, 95 % CI 0.47-1.11). Insufficient data regarding complications, acceptability and satisfaction were available for meta-analysis.

CONCLUSION

Local anaesthesia via any route of genital tract administration, should be considered when undertaking office diagnostic or operative hysteroscopy to reduce pain during and after the procedure. Further research is needed to understand whether the pain control benefits of local anaesthesia remain apparent with vaginoscopic approaches to office hysteroscopy that avoid genital tract instrumentation.

Vaginoscopy Against Standard Treatment: a randomised controlled trial

OBJECTIVE

To evaluate whether vaginoscopy or standard hysteroscopy was more successful in the outpatient setting.

DESIGN

Randomised controlled multicentre trial.

SETTING

Outpatient hysteroscopy clinics at two UK hospitals.

POPULATION

1597 women aged 16 or older undergoing an outpatient hysteroscopy.

METHODS

Women were allocated to vaginoscopy or standard hysteroscopy using third party randomisation stratified by menopausal status with no blinding of participants or clinicians.

MAIN OUTCOME MEASURES

The primary outcome was 'success', a composite endpoint defined as: a complete procedure, no complications, a level of pain acceptable to the patient, and no sign of genitourinary tract infection 2 weeks after the procedure.

RESULTS

Vaginoscopy was significantly more successful than standard hysteroscopy [647/726 (89%) versus 621/734 (85%), respectively; relative risk (RR) 1.05, 95% CI 1.01-1.10; P = 0.01]. The median time taken to complete vaginoscopy was 2 minutes compared with 3 minutes for standard hysteroscopy (P < 0.001). The mean pain score was 42.7 for vaginoscopy, which was significantly less than standard hysteroscopy 46.4 (P = 0.02). Operative complications occurred in five women receiving vaginoscopy and 19 women receiving standard hysteroscopy (RR 0.26, 95% CI 0.10-0.69).

CONCLUSIONS

Vaginoscopy is quicker to perform, less painful, and more successful than standard hysteroscopy and therefore should be considered the technique of choice for outpatient hysteroscopy.

TWEETABLE ABSTRACT

Vaginoscopy is quicker to perform, less painful, and more successful than standard hysteroscopy.

Outcomes in prevention and management of miscarriage trials: a systematic review

BACKGROUND

There is a substantial body of research evaluating ways to prevent and manage miscarriage, but all studies do not report on the same outcomes.

OBJECTIVE

To review systematically, outcomes reported in existing miscarriage trials.

SEARCH STRATEGY

MEDLINE, Embase, CINAHL, and Cochrane were searched from inception until January 2017.

SELECTION CRITERIA

Randomised controlled trials (RCTs) reporting prevention or management of miscarriage. Miscarriage was defined as a pregnancy loss in the first trimester.

DATA COLLECTION AND ANALYSIS

Data about the study characteristics, primary, and secondary outcomes were extracted.

MAIN RESULTS

We retrieved 1553 titles and abstracts, from which 208 RCTs were included. For prevention of miscarriage, the most commonly reported primary outcome was live birth and the top four reported outcomes were pregnancy loss/stillbirth (n = 112), gestation of birth (n = 68), birth dimensions (n = 65), and live birth (n = 49). For these four outcomes, 58 specific measures were used for evaluation. For management of miscarriage, the most commonly reported primary outcome was efficacy of treatment. The top four reported outcomes were bleeding (n = 186), efficacy of miscarriage treatment (n = 105), infection (n = 97), and quality of life (n = 90). For these outcomes, 130 specific measures were used for evaluation.

CONCLUSIONS

Our review found considerable variation in the reporting of primary and secondary outcomes along with the measures used to assess them. There is a need for standardised patient-centred clinical outcomes through the development of a core outcome set; the work from this systematic review will form the foundation of the core outcome set for miscarriage.

TWEETABLE ABSTRACT

There is disparity in the reporting of outcomes and the measures used to assess them in miscarriage trials.

Global Genome Biodiversity Network: saving a blueprint of the Tree of Life - a botanical perspective

BACKGROUND

Genomic research depends upon access to DNA or tissue collected and preserved according to high-quality standards. At present, the collections in most natural history museums do not sufficiently address these standards, making them often hard or impossible to use for whole-genome sequencing or transcriptomics. In response to these challenges, natural history museums, herbaria, botanical gardens and other stakeholders have started to build high-quality biodiversity biobanks. Unfortunately, information about these collections remains fragmented, scattered and largely inaccessible. Without a central registry or even an overview of relevant institutions, it is difficult and time-consuming to locate the needed samples.

SCOPE

The Global Genome Biodiversity Network (GGBN) was created to fill this vacuum by establishing a one-stop access point for locating samples meeting quality standards for genome-scale applications, while complying with national and international legislations and conventions. Increased accessibility to genomic samples will further genomic research and development, conserve genetic resources, help train the next generation of genome researchers and raise the visibility of biodiversity collections. Additionally, the availability of a data-sharing platform will facilitate identification of gaps in the collections, thereby empowering targeted sampling efforts, increasing the breadth and depth of preservation of genetic diversity. The GGBN is rapidly growing and currently has 41 members. The GGBN covers all branches of the Tree of Life, except humans, but here the focus is on a pilot project with emphasis on 'harvesting' the Tree of Life for vascular plant taxa to enable genome-level studies.

CONCLUSION

While current efforts are centred on getting the existing samples of all GGBN members online, a pilot project, GGI-Gardens, has been launched as proof of concept. Over the next 6 years GGI-Gardens aims to add to the GGBN high-quality genetic material from at least one species from each of the approx. 460 vascular plant families and one species from half of the approx. 15 000 vascular plant genera.

The effectiveness of gynaecological teaching associates in teaching pelvic examination: a systematic review and meta-analysis

CONTEXT

An increasing number of graduating students are unable to competently and confidently perform a pelvic examination. Gynaecology teaching associates (GTAs) teach technical and communication skills and offer immediate feedback. The objective was to perform a systematic literature review to assess whether teaching pelvic examinations using real women who are trained to give instructions on technique and feedback improves the competence, confidence and communication skills of trainees when compared with traditional teaching methods.

METHODS

MEDLINE, EMBASE, the Cochrane Library, CINAHL and the ISRCTN Register of Clinical Trials were searched using selected terminology. No language restrictions were applied. The selection criteria were randomised clinical trials (RCTs) and controlled studies that investigated the use of GTAs to teach students or health-related professionals the pelvic examination. Data evaluating study outcomes, along with methodological details, were extracted in duplicate. The outcomes measured were: self-reported confidence, assessed competence and assessed communication skills. The standard mean difference (SMD) was derived for each study where possible and heterogeneity across studies was quantified using the I(2) statistic. In the presence of substantial variation, the data were pooled using a random effects model.

RESULTS

Eleven studies with 856 participants were included: five RCTs and six observational studies. GTA training improved competence compared with other teaching methods and the finding of enhanced competence was consistent when the pooled analysis was restricted to RCTs. Communication skills were also improved with GTA teaching, but to a lesser degree, whereas no effect on student confidence was observed. Statistical heterogeneity was present for all outcomes when data were pooled.

CONCLUSION

Our findings suggest that GTA-based teaching of pelvic examination is associated with improvement in the competence and communication skills of trainees. However, further larger-scale studies with standardised relevant educational outcomes are needed to confirm these findings.

Predicting the chance of live birth for women undergoing IVF: a novel pretreatment counselling tool

STUDY QUESTION

Which pretreatment patient variables have an effect on live birth rates following assisted conception?

SUMMARY ANSWER

The predictors in the final multivariate logistic regression model found to be significantly associated with reduced chances of IVF/ICSI success were increasing age (particularly above 36 years), tubal factor infertility, unexplained infertility and Asian or Black ethnicity.

WHAT IS KNOWN ALREADY

The two most widely recognized prediction models for live birth following IVF were developed on data from 1991 to 2007; pre-dating significant changes in clinical practice. These existing IVF outcome prediction models do not incorporate key pretreatment predictors, such as BMI, ethnicity and ovarian reserve, which are readily available now.

STUDY DESIGN, SIZE, DURATION

In this cohort study a model to predict live birth was derived using data collected from 9915 women who underwent IVF/ICSI treatment at any CARE (Centres for Assisted Reproduction) clinic from 2008 to 2012. Model validation was performed on data collected from 2723 women who underwent treatment in 2013. The primary outcome for the model was live birth, which was defined as any birth event in which at least one baby was born alive and survived for more than 1 month.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Data were collected from 12 fertility clinics within the CARE consortium in the UK. Multivariable logistic regression was used to develop the model. Discriminatory ability was assessed using the area under receiver operating characteristic (AUROC) curve, and calibration was assessed using calibration-in-the-large and the calibration slope test.

MAIN RESULTS AND THE ROLE OF CHANCE

The predictors in the final model were female age, BMI, ethnicity, antral follicle count (AFC), previous live birth, previous miscarriage, cause and duration of infertility. Upon assessing predictive ability, the AUROC curve for the final model and validation cohort was (0.62; 95% confidence interval (CI) 0.61-0.63) and (0.62; 95% CI 0.60-0.64) respectively. Calibration-in-the-large showed a systematic over-estimation of the predicted probability of live birth (Intercept (95% CI) = -0.168 (-0.252 to -0.084), P < 0.001). However, the calibration slope test was not significant (slope (95% CI) = 1.129 (0.893-1.365), P = 0.28). Due to the calibration-in-the-large test being significant we recalibrated the final model. The recalibrated model showed a much-improved calibration.

LIMITATIONS, REASONS FOR CAUTION

Our model is unable to account for factors such as smoking and alcohol that can affect IVF/ICSI outcome and is somewhat restricted to representing the ethnic distribution and outcomes for the UK population only. We were unable to account for socioeconomic status and it may be that by having 75% of the population paying privately for their treatment, the results cannot be generalized to people of all socioeconomic backgrounds. In addition, patients and clinicians should understand this model is designed for use before treatment begins and does not include variables that become available (oocyte, embryo and endometrial) as treatment progresses. Finally, this model is also limited to use prior to first cycle only.

WIDER IMPLICATIONS OF THE FINDINGS

To our knowledge, this is the first study to present a novel, up-to-date model encompassing three readily available prognostic factors; female BMI, ovarian reserve and ethnicity, which have not previously been used in prediction models for IVF outcome. Following geographical validation, the model can be used to build a user-friendly interface to aid decision-making for couples and their clinicians. Thereafter, a feasibility study of its implementation could focus on patient acceptability and quality of decision-making.

STUDY FUNDING/COMPETING INTEREST

None.

Systemic lupus erythematosus: clinical presentations

Systemic lupus erythematosus is a complex multisystem autoimmune disease that affects 1 in 2000 adult women in the United Kingdom. Lupus affects Afrocaribbeans and South Asians more frequently and more severely than white British. The disease can affect almost any part of the body and is characterised by remission and relapses. It is most common in women of reproductive age but can present at any age from 1 to 90 years and in men, but the diagnosis is probably missed in some men. It is important to distinguish active lupus features due to inflammatory and thrombotic mechanisms from chronic damage and to be aware that infection is an important trigger that may co-exist or mimic lupus activity. The disease is associated with a variety of autoantibodies that can help in making the diagnosis. Monitoring the disease is usually done using a clinical disease activity index such as the BILAG index, anti-dsDNA antibodies, C3 and C4 levels. Anti-C1q antibodies may have a role in monitoring the disease and in predicting those at risk of renal involvement or flare. The prognosis depends on the organs involved. There is an increased risk of premature atherosclerosis as a complication of lupus and this and infection are the most common causes of death in lupus patients.

Carbyne forms of carbon: do they exist?

Almost 15 years have passed since carbynes entered the literature as new forms of elemental carbon. They recently attracted attention as possible interstellar dust constituents and as carriers of presolar noble gases in meteorites. Their existence and that of the related mineral chaoite are questioned, and a reevaluation of previous data is suggested.

The role of angiogenic and wound repair factors during CMV-accelerated transplant vascular sclerosis in rat cardiac transplants

Human cytomegalovirus (HCMV) accelerates transplant vascular sclerosis (TVS), a consequence of angiogenesis (AG) and wound repair (WR). While HCMV can be localized to TVS lesions, the low number of infected cells suggests a global effect on target tissues. We used microarray analysis followed by real-time-polymerase chain reaction (RT-PCR) in an RCMV-accelerated TVS rat cardiac transplant model to determine whether CMV activates host WR and AG factors. Dysregulated cellular genes in allografts from RCMV-infected recipients were compared to those from uninfected recipients and native hearts. We demonstrated that RCMV upregulates the genes involved in WR and AG, which was highest during the critical time of TVS acceleration (21-28 days). Using a standard in vitro AG assay, virus and serum-free supernatants collected at 48 h postinfection significantly induced endothelial cell (EC) migration, branching and tubule formation compared to supernatants from mock-infected cells. Supernatants from ultraviolet (UV)-inactivated RCMV-infected cells failed to induce AG, indicating that virus replication is required. Upregulation of WR and AG genes occurs during the critical period of CMV-accelerated TVS. Targeting these genes may prevent this process and improve allograft survival.

The use of sacred story in a psychiatry spirituality group

Describes the philosophy and methodology for using sacred stories from several religious traditions with psychiatric patients. Notes how chaplains are integrated into a psychiatric unit's interdisciplinary team. Details how sacred stories are selected for use in a spirituality group, how patients are screened for participation, and how the group is facilitated. Demonstrates the benefit and value patients and staff derive from a spirituality group on a psychiatric unit.

Reactivation of latent human cytomegalovirus in CD14(+) monocytes is differentiation dependent

We have previously demonstrated reactivation of latent human cytomegalovirus (HCMV) in myeloid lineage cells obtained from healthy donors. Virus was obtained from allogenically stimulated monocyte-derived macrophages (Allo-MDM), but not from macrophages differentiated by mitogenic stimulation (ConA-MDM). In the present study, the cellular and cytokine components essential for HCMV replication and reactivation were examined in Allo-MDM. The importance of both CD4(+) and CD8(+) T cells in the generation of HCMV-permissive Allo-MDM was demonstrated by negative selection or blocking experiments using antibodies directed against both HLA class I and HLA class II molecules. Interestingly, contact of monocytes with CD4 or CD8 T cells was not essential for reactivation of HCMV, since virus was observed in macrophages derived from CD14(+) monocytes stimulated by supernatants produced by allogeneic stimulation of peripheral blood mononuclear cells. Examination of the cytokines produced in Allo-MDM and ConA-MDM cultures indicated a significant difference in the kinetics of production and quantity of these factors. Further examination of the cytokines essential for the generation of HCMV-permissive Allo-MDM identified gamma interferon (IFN-gamma) but not interleukin-1 or -2, tumor necrosis factor alpha, or granulocyte-macrophage colony-stimulating factor as critical components in the generation of these macrophages. In addition, although IFN-gamma was crucial for reactivation of latent HCMV, addition of IFN-gamma to unstimulated macrophage cultures was insufficient to reactivate virus. Thus, this study characterizes two distinct monocyte-derived cell types which can be distinguished by their ability to reactivate and support HCMV replication and identifies the critical importance of IFN-gamma in the reactivation of HCMV.

Long-term infection and transformation of dermal microvascular endothelial cells by human herpesvirus 8

Human herpesvirus 8 (HHV8) infects Kaposi's sarcoma (KS) spindle cells in situ, as well as the lesional endothelial cells considered to be spindle cell precursors. The HHV8 genome contains several oncogenes, suggesting that infection of endothelial and spindle cells could induce cellular transformation and tumorigenesis and promote the formation of KS lesions. To investigate the potential of HHV8 infection of endothelial cells to contribute to the development of KS, we have developed an in vitro model utilizing dermal microvascular endothelial cells that support significant HHV8 infection. In contrast to existing in vitro systems used to study HHV8 pathogenesis, the majority of dermal endothelial cells are infected with HHV8 and the viral genome is maintained indefinitely. Infection is predominantly latent, with a small percentage of cells supporting lytic replication, and latency is responsive to lytic induction stimuli. Infected endothelial cells develop a spindle shape resembling that of KS lesional cells and show characteristics of a transformed phenotype, including loss of contact inhibition and acquisition of anchorage-independent growth. These results describe a relevant model system in which to study virus-host interactions in vitro and demonstrate the ability of HHV8 to induce phenotypic changes in infected endothelial cells that resemble characteristics of KS spindle cells in vivo. Thus, our results are consistent with a direct role for HHV8 in the pathogenesis of KS.

Human cytomegalovirus infection of caco-2 cells occurs at the basolateral membrane and is differentiation state dependent

Epithelial cells are known to be a major target for human cytomegalovirus (HCMV) infection; however, the analysis of virus-cell interactions has been difficult to approach due to the lack of in vitro models. In this study, we established a polarized epithelial cell model using a colon epithelial cell-derived cell line (Caco-2) that is susceptible to HCMV infection at early stages of cellular differentiation. Infection of polarized cells was restricted to the basolateral surface whereas virus was released apically, which was consistent with the apical and not basolateral surface localization of two essential viral glycoproteins, gB and gH. HCMV infection resulted in the development of a cytopathology characteristic of HCMV infection of colon epithelium in vivo, and infection did not spread from cell to cell. The inability of HCMV to infect Caco-2 cells at late stages of differentiation was due to a restriction at the level of viral entry and was consistent with the sequestration of a cellular receptor for HCMV. These observations provide the first evidence that restriction of HCMV replication in epithelial cells is due to a receptor-mediated phenomenon.

A guide to finding and evaluating best practices health care information on the Internet: the truth is out there?

BACKGROUND

The advent of virtually free Internet access has opened large vistas of health care information to those willing to invest a small amount of time and energy learning how to perform searches using browser software. Health care providers, organizations, and professional associations, among many others, publish "best practices" information for both administrative and clinical audiences, making these recommendations among the fastest-growing types of health care information appearing on the World Wide Web. The problem is how to find best practices among the wealth of resources on the Internet and then how to separate the proverbial wheat from the chaff. WHO IS SEEKING BEST PRACTICES ON THE INTERNET? Best practice describes a process or technique whose employment results in improved patient and/or organizational outcomes. Health care providers, managed care organizations, administrators, payers, and policy analysts are all interested in improving the quality of health care and are likely to be customers of best practices informational resources. HOW TO EVALUATE THE QUALITY OF BEST PRACTICES INFORMATION? Once the information is available on the Internet, the problem for the searcher shifts from one of quantity to quality. The best practices information seeker should stop and ask a number of questions about the quality of information, its sources, and the methods used to obtain it.

CONCLUSION

The "truth" may be out there some-where in cyberspace, but locating best practices information and evaluating its quality require new skills and patience and time to practice and develop them to the point of efficiency.

The enhancer domain of the human cytomegalovirus major immediate-early promoter determines cell type-specific expression in transgenic mice

The human cytomegalovirus (HCMV) major immediate-early promoter (MIEP) is one of the first promoters to activate upon infection. To examine HCMV MIEP tissue-specific expression, transgenic mice were established containing the lacZ gene regulated by the MIEP (nucleotides -670 to +54). In the transgenic mice, lacZ expression was demonstrated in 19 of 29 tissues tested by histochemical and immunochemical analyses. These tissues included brain, eye, spinal cord, esophagus, stomach, pancreas, kidney, bladder, testis, ovary, spleen, salivary gland, thymus, bone marrow, skin, cartilage, and cardiac, striated and smooth muscles. Although expression was observed in multiple organs, promoter activity was restricted to specific cell types. The cell types which demonstrated HCMV MIEP expression included retinal cells of the eye, ductile cells of the salivary gland, exocrine cells of the pancreas, mucosal cells of the stomach and intestine, neuronal cells of the brain, muscle fibers, thecal cells of the corpus luteum, and Leydig and sperm cells of the testis. These observations indicate that the HCMV MIEP is not a pan-specific promoter and that the majority of expressing tissues correlate with tissues naturally infected by the virus in the human host.

Developmental analysis of the cytomegalovirus enhancer in transgenic animals

The major immediate-early promoter (MIEP) of human, cytomegalovirus (HCMV) constitutes a primary genetic switch for viral activation. In this study, regulation of the enhancer-containing segment (nucleotides -670 to +54) of the HCMV MIEP attached to the 1acZ reporter gene was examined in the developing embryos of transgenic mice to identify temporal and tissue-specific expression. We find that the transgene reporter is first detected as a dorsal stripe of expression in the neural folds of embryos at day 8.5 postcoitum (p.c.). A broad expression pattern is exhibited in embryos at day 9.5 p.c. This pattern becomes more restricted by day 10.5 p.c. as organogenesis progresses. By day 14.5 p.c., prominent expression is observed in a subpopulation of central nervous system cells and spinal ganglia, endothelial cells, muscle, skin, thyroid, parathyroid, kidney, lung, liver, and gut cells, and the pancreas and submandibular and pituitary glands. This distribution pattern is discussed in relation to human congenital HCMV infection. These results suggest that the transcriptional activity of the HCMV MIEP may determine in part, the ability of the virus to specifically target developing fetal tissues in utero.

Isolation and characterization of adenovirus-associated VA RNAs of human adenovirus type 7

Two genes for virus-associated VA RNAs in the human adenovirus type 7 (Ad7) genome are compared to Ad2, Ad4, Ad5, simian VA RNAs, and pol III transcripts of Epstein-Barr virus. The newly identified VA RNA-encoding genes of Ad7 contain two relatively conserved intragenic promoter (elements A and B), the double-stranded RNA-dependent protein kinase (PK) active site-binding domain and transcriptional terminators. The conserved features extend to the VA RNA genes of simian and avian origin.

Restoration of telomeres in human papillomavirus-immortalized human anogenital epithelial cells

Loss of telomeres has been hypothesized to be important in cellular senescence and may play a role in carcinogenesis. In this study, we have measured telomere length in association with the immortalization and transformation of human cervical and foreskin epithelial cells by the human papillomavirus type 16 or 18 E6 and E7 open reading frames. By using a telomeric TTAGGG repeat probe, it was shown that the telomeres of precrisis normal and E6-, E7-, and E6/E7-expressing cells gradually shortened with passaging (30 to 100 bp per population doubling). Cells that expressed both E6 and E7 went through a crisis period and gave rise to immortalized lines. In contrast to precrisis cells, E6/E7-immortalized cells generally showed an increase in telomere length as they were passaged in culture, with some later passage lines having telomeres that were similar to or longer than the earliest-passage precrisis cells examined. No consistent association could be made between telomere length and tumorigenicity of cells in nude mice. However, of the three cell lines that grew in vivo, two had long telomeres, thus arguing against the hypothesis that cancer cells favor shortened telomeres. Our results indicate that arrest of telomere shortening may be important in human papillomavirus-associated immortalization and that restoration of telomere length may be advantageous to cells with regard to their ability to proliferate.

Interaction of HPV-18 and nitrosomethylurea in the induction of squamous cell carcinoma

A strong correlation exists between the presence of specific types of human papillomavirus (HPV) and the development of anogenital cancer, as well as significant epidemiologic evidence suggesting smokers are at increased risk of developing cervical, vulvar and/or anal carcinomas. Primary and human papillomavirus type 18 (HPV-8)-immortalized human keratinocytes were used to address the co-carcinogenic potential of HPV and nitrosomethylurea (NMU) in tumorigenesis. Only cells containing HPV-18 and treated with NMU and the tumor-promoting phorbol ester, TPA, were transformed to a malignant phenotype. An in vitro system is described which initiates studies involving the mechanisms of HPV and chemical carcinogen co-operation in the etiology of squamous cell carcinomas.

Alteration of the DCC tumor-suppressor gene in tumorigenic HPV-18 immortalized human keratinocytes transformed by nitrosomethylurea

A human papillomavirus type 18 (HPV-18)-immortalized human keratinocyte cell line (1811) has been transformed to tumorigenicity in nude mice by treatment with the carcinogen nitrosomethylurea (NMU). The NMU transformants (1811-NMU-T) showed additional chromosome alterations as compared with parental 1811 cells, including 18q deletion in two of two 1811-NMU-T lines analysed. Restriction fragment length polymorphism (RFLP) analysis indicated that both 1811-NMU-T lines had lost one allele of the 18q deleted in colon cancer (DCC) tumor-suppressor gene. Reverse transcriptase polymerase chain reaction (RT-PCR) showed that DCC expression was absent or barely detectable in the 1811-NMU-T cells as compared with 1811 or normal keratinocytes, suggesting that the remaining DCC allele in the 1811-NMU-T cells was also altered. These studies indicate that reduction or loss of DCC expression may be an important step in NMU transformation of HPV-immortalized cells to tumorigenicity.

Viral integration and fragile sites in human papillomavirus-immortalized human keratinocyte cell lines

Human papillomavirus (HPV) types 16 and 18 integration sites were mapped in six HPV-immortalized human keratinocyte cell lines by fluorescence in situ hybridization (FISH). Mapping of HPV sequences in these cell lines revealed that HPV integration varied in copy number and location but that integration sites were stable over extended passages in culture. Integration occurred at different sites throughout the genome and did not correspond to the location of specific cellular genes. However, integration sites were consistent with integration near or within known fragile sites in five of the six cell lines. Induction of aphidicolin-sensitive fragile sites in one cell line prior to in situ hybridization revealed that integrated HPV DNA was disrupted by fragile-site expression, suggesting that integration occurred within a fragile site.

Immortalization of primary human smooth muscle cells

Primary human aortic and myometrial smooth muscle cells (SMCs) were immortalized using an amphotropic recombinant retroviral construct containing the E6 and E7 open reading frames (ORFs) of human papillomavirus type 16. The SMCs expressing the E6/E7 ORFs have considerably elevated growth rates when compared with nonimmortalized control cells and show no signs of senescence with long-term passage. The first SMC line derived in this study has been maintained in continuous tissue culture for greater than 1 year (greater than 180 population doublings). The immortalized SMCs have decreased cell size and decreased content of muscle-specific alpha-actin filaments as determined by indirect immunofluorescence. Southern blot analysis has demonstrated the stable integration of the E6/E7 ORFs in the retrovirally infected cells, and radioimmunoprecipitation has confirmed the continued expression of the E6 and E7 genes. Cytogenetic studies of the SMC lines have revealed essentially diploid populations except for the myometrial clonal line, which became aneuploid at late passage (greater than 125 doublings). These cell lines were not tumorigenic in nude mice.

Progression of human papillomavirus type 18-immortalized human keratinocytes to a malignant phenotype

We have developed a model system for progression of human epithelial cells to malignancy, using a human papillomavirus type 18 (HPV-18)-immortalized human keratinocyte cell line. Cells of cell line FEP-1811 were nontumorigenic in athymic mice through at least 12 passages in culture, but after 32 passages were weakly tumorigenic, producing tumors that regressed. After 62 passages they produced invasive squamous cell carcinomas that grew progressively. The progression to malignancy was associated with an increase in the efficiency of forming colonies in soft agar and with altered differentiation properties. In an organotypic culture system, FEP-1811 cells at passages 12 and 32 exhibited features typical of premalignant intraepithelial neoplasia in vivo, and cells at passage 68 exhibited features consistent with squamous cell carcinomas. No change in copy number of the transfected HPV-18 genome or in the level of expression of the viral transforming gene products E6 and E7 was detected between tumorigenic and nontumorigenic cells. Cytogenetic analysis of cells at early, middle, and late passage levels and cells cultured from tumors revealed that several chromosomal abnormalities segregated with the tumorigenic cell populations.

Cytogenetic analysis of eight human papillomavirus immortalized human keratinocyte cell lines

Cytogenetic analysis was performed on human papillomavirus (HPV)-immortalized cell lines. Lines were established by co-transfection of primary human keratinocyte cells with HPV type 16 or 18 DNA and pSV2neo. The resulting clonal lines contained integrated HPV DNA and exhibited extended life spans in culture but were non-tumorigenic in nude mice. Two HPV16-immortalized lines (FEPE1L8 and FEPE1L9) and 4 HPV18-immortalized lines (FEA, FEH18L, FEP18-5 and FEP18-11) were established. Two additional lines were derived by subsequent treatment of the FEA line with TPA and by further transfection with HSVII DNA. Cytogenetic analysis revealed that all lines were abnormal, containing a variety of numerical and structural aberrations. Six of the 8 lines were hyper-triploid and 2 were near-diploid. Examination of lines FEA, FEH18L and FEP18-11 at multiple passages in culture revealed that the lines were clonal and chromosomally stable over extended passage in culture. Structural rearrangements were most common in chromosomes 1 and 3 but also occurred in chromosomes 5, 7, 8, 12, 16 and 22. Marker chromosomes were present in all cell lines. A small metacentric marker, possibly an isochromosome for the short arm of chromosome 5, was consistently present in the FEA line and its derivatives (FEAB10 and FEAT) as well as the FEH18L line. A loss or reduction in copy number of chromosome 13 was seen in 5 of the 8 cell lines.

A fragile site in the human U2 small nuclear RNA gene cluster is revealed by adenovirus type 12 infection

Using in situ hybridization, we found that the U2 small nuclear RNA gene cluster mapped very close to and was frequently disrupted by the gaps and breaks induced specifically in the human 17q21-q22 region by highly oncogenic adenovirus type 12 (Ad12). Restriction mapping revealed no structural alterations in the U2 gene locus as a result of Ad12 infection. Likewise, no Ad12-induced alterations in U2 RNA levels were detected. We estimate that the maximum size of the region specifically disrupted by this virus was less than 350 to 700 kilobases. A comparison of these data with similar data regarding biochemically induced fragile sites was made.

Improvement in disequilibrium symptoms during dialysis with low glucose dialyzate

This study compares the frequency of dialysis disequilibrium symptoms (DDS), in 17 stable non-diabetic chronic hemodialysis patients, during a period using low glucose (200 mg/100 ml) dialyzate to a similar period using a glucose free dialyzate. There was a significant decrease in the total number of symptoms as well as the frequency of headache and post-dialysis fatigue during the low glucose period as compared to the glucose free period. The decrease in nausea or vomiting, and cramps was not significant while frequency of hypotension was unchanged. Evaluation of serum sodium, potassium, BUN, glucose and osmolarity did not reveal significant differences during the two periods. Dialysis with a low glucose bath produces less DDS than glucose free dialyzate.

Graphitic carbon in the Allende meteorite: a microstructural study

High-resolution transmission electron microscopy, shows that carbon in the Allende carbonaceous chondrite meteorite is predominantly a poorly crystalline graphite. Such material is of interest as an important carrier of the isotopically anomalous noble gases found in carbonaceous chondrites.